NOTES FROM GUTMAN LECTURE 10/26
Use this outline to study from. As you go through Gutman’s lecture, fill in the topics.
Anatomy above the arcuate line
Skin
Camper’s fascia
Scarpa’s fascia
External oblique aponeurosis
Internal oblique aponeurosis
Rectus muscle
Internal oblique aponeurosis
Transversus abdominis muscle
Transversalis fascia
peritoneum
below the arcuate line
Skin
Camper’s fascia
Scarpa’s fascia
External oblique aponeurosis
Internal oblique aponeurosis
Rectus muscle
Transversus abdominis muscle
Transversalis fascia
peritoneum
Anterior Abdominal Wall landmarks
Median umbilical foldsMedial umbilical folds –
Lateral umbilical folds–
Bones of pelvis
Sacrum
Coccyx
Innominate bones
Pubis
Ischium
Ilium
Sacrotuberous – ischial tuberosity Æsacrum
Sacrospinous – ischil spine Æ sacrum
Anterior longitudinal ligament (ASC)
Anal coccygeal ligament
Pectineal ligament = Cooper’s ligament - along pectin pubis (Burch retropubic
urethropexy)
Pelvimetry
Inlet
true conjugate - AP diameter from superior margin pubic symphysis to
sacral promontory (11cm)
Obstetric conjugate – AP diameter that runs from back of pubic symphysis
to sacral promontory (10cm), smallest conjugate.
Diagonal conjugate – AP diameter from inferior margin of pubic
symphysis to sacral promontory (11.5cm)
Oblique diameter – from sacroiliac joint to contralateral iliopubic
eminence (<13cm)
Transverse diameter – widest distance across the pelvic brim (13.5cm)
Midplane
Outlet
Pelvic shapes
Gynecoid –
Android –
Anthropoid –
Platypelloid –
interspinous diameter - (10cm), smallest diameter, very important
obstetrically. Site of deep transverse arrest. <9.5cm and there is a 50%
chance of intervention during childbirth
Transverse diameter – intertuberoud diameter - distance between
ischial tuberosities (11.5cm)
AP diameter – inferior aspect of pubic symphysis to tip of coccyx (10cm)
Pubic arch
Pelvic Vasculature
External iliac
Inferior epigastric artery (under fascia)
Deep circumflex artery
Æfemoral artery (passes through inguinal ligament)
Internal iliac/hypogastric
Anterior
Obliterated umbilical Æ superior vesical
Uterine Ævaginal
Middle rectal (hemorrhoidal)
Obturator
Inferior gluteal
Internal pudendal Æ inferior rectal
Posterior
Iliolumbar
Lateral sacral
Superior gluteal
Collateral Circulation after hypogastric artery ligation
Anterior div
Systemic
middle rectal (hypogastric)
superior rectal (IMA)
inferior rectal (hypogastric)
Middle sacral
Lumbar
Hypogastric artery ligation
Right angle clamp
2.5 - 3.0 cm distal to bifurcation of common iliac artery
lateral Æ medial to void vein
double ligate with 1-0 silk, don’t divide
repeat on contralateral side
Course of Pudendal artery and nerve
Behind ischial spine
Out greater sciatic
In lesser sciatic
Through alcock
3 branches of pudendal artery
Inferior rectal
Perineal
Clitoral
Posterior div
lateral sacral
iliolumbar
Blood supply to the ureter
Renal
Ovarian
Aorta
Iliac/hypogastric
Superior vesical
Inferior vesical artery
Blood supply to colon/rectum
SMA - proximal 1/3 colon
IMA (L2-3) - distal 1/3 transverse colon, descending colon, sigmoid colon, rectum
--left colic
--sigmoidal
--superior rectal (IMA)
Middle rectal (hypogastric)
Inferior rectal (pudendal)
Nerves of pelvis
Iliohypogastric (L1)
Ilioinguinal (L2)
Genitofemoral (L1-2)
Lateral femoral cutaneous (L2-3)
Femoral (L2-4, post)
Obturator (L2-4)
Sciatic (L4-5, S1-3 through greater sciatic foramen)
Common perineal nerve (branch of sciatic)
Muscles of the pelvic girdle
Iliacus – flexes hip
Psoas major – flexes body at hip and waist
Piriformis – lateral rotator of hip
Obturator externus and internus – lateral rotater of hip
Levator ani (puborectalis, pubococcygeus, iliococcygeus)
Coccygeus
Superior hypogstric plexus = presacral nerve
Hypogastric nerge
Inferior hypogastric
Pudendal Nerve Block
Surgical Spaces
Prevesical (space of Retzius)
Vesicovaginal and vesicocervical
Paravesical
Rectovaginal
Pararectal
Retrorectal
Presacral
Perineum
Anterior triangle
Posterior triangle
Compressor urethrae
Urethrae sphincter
Pelvic diaphragm
Levator ani
Puborectalis (90 degree anorectal angle))
Pubococcycges
Iliococcygeus
Coccygeus
Function of pelvis diaphragm
Close genital hiatos
Create levator plate
Anal Continence Mechanism
Delancey level of support
1 - uterosacral, cardinal ligaments, support uterus and vaginal apex
2 - lateral attachements of endopelvic fascia and vagina to arcus tendineus fascia
pelvis, support bladder, vagina and rectum
3 – perineal membrana and perineal body, support urethrovesical junction and
perineum
Uterosacral ligament suspensión
Rectovaginal fascia attachments
“boat in dry dock”